Laser Vision Consultation

Name

Date

Street Address City State ZIP Code

Date of Birth

Age

Occupation

Preferred phone

Preferred email

Emergency contact

Phone

Relationship

How would you prefer we contact you?

Call
Text
Email

Whom should we thank for your referral?

Favorite hobbies/sports?

Vision issues for work?

Yes
No

EYE CONDITIONS

Do you have any of the following eye conditions?

Glaucoma?

Yes
No

Cataracts?

Yes
No

Retinal detachment/problems?

Yes
No

Lazy eye/amblyopia?

Yes
No

Eye surgery?

Yes
No

Dry eye?

Yes
No

Eye injury/infection?

Yes
No

Family history of eye disease?

Yes
No

VISION HISTORY

Please tell us about your vision history.

When was your last eye exam?

Eye doctor's name / City:

How often do you wear contacts/glasses?

All the time
Distance only
Reading only
Rarely

How old are your present glasses?

Do you wear contact lenses?

Yes
No

And are your contacts...?

Do you have problems wearing contacts?

Yes
No

Last date contacts worn?

MEDICAL CONDITIONS

Please tell us about your overall health.

Rheumatoid arthritis?

Yes
No

Collagen/Vascular disease?

Yes
No

Systemic lupus?

Yes
No

Chronic or recurrent arthritis?

Yes
No

Autoimmune disorder?

Yes
No

Allergic to medications?

Yes
No

Please list your medication allergies:

Prescription medications?

Yes
No

Please list your prescription medications:

Family history of health issues?

Yes
No

Are you pregnant or nursing?

Yes
No

Please list:

OTHER EYE PROBLEMS

Have you been diagnosed with any of the following eye conditions?

Iritis or Uveitis?

Yes
No

Herpes infection in eye?

Yes
No

Keratoconus?

Yes
No

Current Eye injury?

Yes
No

Prior eye injury?

Yes
No

Free consultation consists of the following:

Measurement of your uncorrected and best-corrected vision.
Measurement of your current eyeglass prescription.
Automated measurement of your refraction (best current prescription).
Measurement of corneal topography, corneal thickness and other necessary tests
Measurement of pupil size in darkness.
Assessment of overall health of the eyes and general medical health.
Based upon the above information, our surgeons and staff should be able to advise you about your candidacy for LASIK and/or other methods of vision correction.

In certain circumstances, additional testing, discussion, or time may be necessary to complete our assessment and give you our best recommendations. If this is the case, you will be advised that the fees will be incurred for additional consultative services. This may be warranted, for example, if any of the following apply:

If multiple visits are advised for any reason, such as (a) repeat refraction after stopping wear of hard lenses, to determine stability; (b) if treatment of medical conditions of the eyes or eyelids is advised prior to contemplating surgery; etc.
If extended consultation is required due to individual circumstances or special needs. Examples might include (a) individuals with reduced vision in one eye; (b) if you have had prior laser or other eye surgery;
If measurements made as a part of our free consultation warrant extra time, caution, or consideration, as might be appropriate in the case of (a) very high corrections; (b) borderline or thin corneal tissue readings; (c) excessively steep or flat corneal curvature as determined by topographic mapping; (d) small corneal diameter; (e) unusual eyelid configuration, presence of lid disease, or incomplete eyelid closure; (e) very large pupil size; (f) presence of ocular surface disease, significant "dry eye" status, or the like; etc.
If testing or several-day trial in soft contact lenses is advised
If you desire monovision and have not yet tried this type of correction (through use of soft contact lenses), in which case we would recommend an appropriate fitting and trial of such lenses.

After completing the free consultation, if Dr. Wallace, Dr. Moarefi and/or staff at LA Sight feel that additional time and or professional services are warranted, you will be so advised. We will inform you of the relevant charges and ask you to sign in the space blow indicating your acknowledgement and acceptance of responsibility for this care. Should you choose to proceed with elective vision correction care at LA Sight, or should you desire medical services above and beyond the scope of vision correction consultation that may be covered by health insurance, we ask that you sign this acknowledgement.

Signature

Date